Grievance and Appeals Nurse (hybrid)

Blue Cross Blue Shield of Arizona
United States, Arizona, Phoenix
2444 W Las Palmaritas Dr (Show on map)
Nov 21, 2024
Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy.AZ Blue offersa variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions. Purpose of the job This position serves as a clinical and administrative subject matter expert for Part C and Part D grievance and appeal functions; investigating and identifying member, provider and/or claim processing appeals and customer service grievances issues; and ensuring that investigation, resolution, and responses are processed promptly in accordance with CMS requirements and timelines. Qualifications REQUIRED QUALIFICATIONS Required Work Experience 5 years of work experience with CMS member services, prior authorizations, appeal, and grievance, or claims functions. Required Education Associate's Degree in a healthcare field of study or Nursing Diploma Required Licenses A current, active, unrestricted nursing license in the state of Arizona (a state in the United States) or another state in the United States recognized by the Nursing Licensure Compact (NLC) as an LPN or RN. Required Certifications N/A PREFERRED QUALIFICATIONS Preferred Work Experience 3 years prior work experience in a managed care environment. Preferred Education Bachelor's degree in general studies, nursing, or business administration Preferred Licenses N/A Preferred Certifications N/A ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES Maintains a thorough understanding of Health Plan operations and business unit processes, workflows and system requirements, including, but not limited to, plan benefits as outlined in the Explanation of Coverage (EOC) documents, authorizations, referrals, network and non-network provider claims, and regulatory compliance. Maintains a current knowledge of CMS rules and regulations relating to the grievance and appeal processes. Participates in CMS and other audits and related activities as required. Coordinates investigation and resolution of complex grievance and appeal issues, reviews information provided by members, providers, and other interested parties regarding grievance and appeal cases, collects and analyzes supporting documentation, and makes the appropriate decisions involving grievance and appeal determinations. Performs all assigned functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Provides an excellent service experience to internal and external customers by consistently demonstrating our core and leadership behaviors each and every day. The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements. Perform all other duties as assigned. Competencies REQUIRED COMPETENCIES Required Job Skills Working knowledge of CMS Managed Care Manual Chapter 13 - Beneficiary Grievances, Organization Determinations, and Appeals and CMS Prescription Drug Benefit Manual Chapter 18 - Part D Enrollee Grievances, Coverage Determinations, and Appeals, knowledge of healthcare billing and claims adjudication processes Familiarity with medical terminology, ICD, CPT, HCPCS, and DRG codes, accurate and efficient keyboarding skills, and the ability to work effectively with common office software. Math, communications and business skills normally demonstrated by a high school degree or equivalent. Required Professional Competencies Demonstrated ability to evaluate and interpret medical records and health plan benefit documents to make appropriate benefit determinations. Must possess highly developed interpersonal skills and communications skills, with a strong customer service orientation. Required Leadership Experience and Competencies N/A PREFERRED COMPETENCIES Preferred Job Skills N/A Preferred Professional Competencies N/A Preferred Leadership Experience and Competencies N/A Our Commitment AZ Blue does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group. Thank you for your interest in Blue Cross Blue Shield of Arizona. For more information on our company, see azblue.com. If interested in this position, please apply.